Immediate and early behavioral

interventions for the prevention

of acute and posttraumatic stress disorderAgorastos Agorastosa, Charles R. Marmarb and Christian Ottec

aDepartment of Psychiatry and Psychotherapy,University Medical Center Hamburg-Eppendorf,Hamburg, Germany, bDepartment of Psychiatry,Langone Medical Center, New York University, NewYork, USA and cDepartment of Psychiatry andPsychotherapy, Charite University Medical Center,Campus Benjamin Franklin, Berlin, Germany

Correspondence to Agorastos Agorastos, MD,University Medical Centre Hamburg-Eppendorf,Department of Psychiatry and Psychotherapy, MartiniStreet 52, 20246 Hamburg, GermanyE-mail: aagorast@uke.uni-hamburg.de

Current Opinion in Psychiatry 2011, 24:526–532

Purpose of review

The development of acute and posttraumatic stress symptoms after a traumatic event is

common and often leads to personal distress, functional impairment, and economic

consequences in trauma victims and their loved ones. Hence, the prevention of acute

and chronic posttraumatic stress is an important public health priority. This article aims

to review the current evidence regarding immediate (within hours) and early (within days

and weeks) psychological and behavioral interventions to prevent posttraumatic stress

symptoms.

Recent findings

Acute distress management, psychological debriefing and other immediate unspecific

interventions within the first hours following a traumatic event have so far not

demonstrated efficacy in preventing posttraumatic stress symptoms. So far, there are no

randomized controlled trials (RCTs) that have examined immediate trauma-focused

cognitive behavioral interventions. In contrast, some, but not many, studies have shown

that cognitive behavioral interventions are efficacious if administered within days or

weeks after a traumatic event. For other early interventions after trauma exposure, there

is no, or only weak, evidence in support of their efficacy. However, conclusions are

limited by the small numbers of trials examining immediate and early interventions.

Summary

Today, there is no empirical evidence to support any immediate intervention within hours

after the traumatic event to prevent posttraumatic stress symptoms.With regard to early

interventions in the first days or weeks after trauma, literature is also sparse, but

supports brief cognitive behavioral interventions as a first choice. There is an urgent

need for RCTs to examine if behavioral interventions immediately following a traumatic

event might be able to reduce the burden of acute and posttraumatic stress symptoms.

Keywords

cognitive behavioral therapy, posttraumatic stress disorder, prevention, trauma,

treatment

Curr Opin Psychiatry 24:526–532� 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins0951-7367

Introduction

Posttraumatic stress symptoms and especially posttrau-

matic stress disorder (PTSD) often lead to personal

distress, impairments in functioning, and economic con-

sequences in trauma victims and their loved ones, thus

representing a major public health issue. Therefore,

interventions following a traumatic event that aim to

prevent posttraumatic stress symptoms or full-blown

PTSD have gained interest over the last years. Several

psychological approaches have been specifically designed

as preventive interventions after traumatic exposure to

decrease the likelihood of subsequent PTSD. However,

most of them have been implemented despite a lack of

evidence. Recently, several reviews and meta-analyses

have tried to assess and summarize empirical data on

the efficacy of psychological interventions following

0951-7367 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

trauma exposure [1–10,11�,12] and have come to incon-

clusive results. Furthermore, randomized controlled trials

(RCTs), as well as open studies in the field, are still

sparse. The purpose of this review is to summarize and

discuss the current evidence on immediate (within hours)

and early (within days or weeks) behavioral interventions

that aim to prevent PTSD.

Definition, symptomatology andepidemiology of posttraumatic stressdisorderPTSD is an anxiety disorder with characteristic symp-

toms following a distressing event that is outside the

range of usual human experience [Diagnostic and

Statistical Manual of Mental Disorders (DSM)-IV,

American Psychiatric Association, [13]]. The traumatic

DOI:10.1097/YCO.0b013e32834cdde2

Behavioral interventions after trauma Agorastos et al. 527

Key points

� No psychological interventions administered in the

first hours, or even the first 72 h, have proven efficacy

for preventing posttraumatic stress symptoms.

� So far, there are no randomized controlled trials

(RCTs) that have examined immediate trauma-

focused cognitive behavioral interventions.

� Early trauma-focused cognitive behavioral therapy

interventions in the first weeks after trauma

exposure show the strongest evidence and appear

to be most efficient in the prevention of acute and

posttraumatic symptoms.

� For other early interventions after trauma exposure,

there is no or only weak evidence in support of

their efficacy.

� Further RCTs are urgently needed to determine

the best time point for behavioral interventions

after trauma exposure, the efficacy of different

types of behavioral interventions, and which indi-

viduals might benefit the most from these inter-

ventions.

event needs to include a serious threat to life or physical

integrity of self or others, accompanied by fear, help-

lessness, or horror. The nature of the traumatic event

can include psychological, physical or sexual abuse,

war-related traumas, man-made and natural disasters,

as well as accidents and physical injuries, and may be

a single incident or of recurring nature.

The three main dimensions of PTSD are re-experiencing

the traumatic event, avoidance of stimuli associated

with the event and numbing of emotions, and increased

arousal (DSM-IV, American Psychiatric Association [13]).

Further posttraumatic symptoms may include diffuse

anxiety, dissociation, helplessness, cognitive impairment,

dysphoria, relationship problems, alcohol and substance

abuse, depression, and suicidal ideation [14–19].

Based on community studies, it is currently estimated that

the rates of lifetime traumaexposure rangebetween50 and

90% and the lifetime prevalence of PTSD between 5 and

10% (12-month rates 2–5%) [19–22]. Although chronic

PTSD can be treated, there are obvious benefits of

preventing the development of the disorder in the first

place [12] in order to avoid short and long-term personal,

psychosocial, and economic consequences [23,24].

Predictors and psychobiological backgroundof posttraumatic stress disorderFemale sex, minority status, younger age, and low socio-

economic and educational status increase the overall risk

of an individual to develop PTSD [25]. Further predic-

tors of development of PTSD following exposure to a

traumatic event include history of prior trauma, personal

and family history of mental illness, lower levels of

perceived social support, higher levels of trauma

exposure and greater perceived life threat during trauma

[26–28]. In addition, peritraumatic symptoms that are

thought to be associated with adrenergic hyperactivation,

such as peritraumatic distress/arousal and dissociation

and peritraumatic-increased heart rate, have been found

to predict PTSD [26,27,29–31]. Potential mechanisms by

which peritraumatic adrenergic hyperactivation might

increase the risk for PTSD include enhanced fear con-

ditioning [32], over-consolidation of traumatic memories,

and disruption of memory processing [33–36].

Prevention of posttraumatic stress disorderAccording to these findings, targeting the acute response

to trauma and its neurobiological underpinnings

represent important research fields in the prevention of

PTSD. In particular, the first hours following the trauma

may be a critical window for interventions aiming at the

prevention or reduction of posttraumatic anxiety [37,38]

and have been characterized as the ‘golden hour(s)’ after

trauma [5]. Animal and human studies have shown that

memory consolidation occurs during the first night’s sleep

following exposure [39–42], supporting the rationale for

immediate intervention. However, relatively few studies

have investigated the effects of different specific treat-

ment strategies, provided within the first hours after

trauma, as immediate prophylactic interventions for indi-

viduals at risk for developing PTSD [12].

There are some encouraging results from immediate-

intervention pharmacological trials in the acute treatment

of posttraumatic stress by various substances (i.e. gluco-

corticoids, selective serotonin reuptake inhibitors, opiates/

morphine, b-blockers, omega-3 fatty acids) [43–47], but

this is beyond the scope of the current article. Further-

more, replication of these single trials is needed and

medication is not always feasible. Routine administration

ofmedication in the acute aftermath of a traumatic event is

restricted by medical, ethical, procedural, legal and

budgetary limitations [10,12,48,49]. Pharmacological

interventions also fail to provide individuals with any tools

and strategies applicable in the management of posttrau-

matic symptoms over the subsequent weeks and months.

An alternative approach is the implementation of preven-

tive psychological and behavioral interventions [10].

Preventive psychological and behavioralinterventions after traumatic exposureImmediate and early preventive behavioral interventions

after a traumatic event are specifically designed to

decrease the likelihood of subsequent PTSD. The over-

all goal of such interventions is to help the traumatized

528 Clinical therapeutics

person regain emotional control, restore interpersonal

communications, and encourage the return to full func-

tion and activity [5]. However, although such approaches

are used widely and are assumed to be beneficial, empiri-

cal data on their efficacy is limited.

This article focuses on immediate and early psychological

and behavioral interventions for adults exposed to a

traumatic event.

Immediate interventionsThis chapter focuses on interventions applied within the

first hours after trauma exposure.

Acute distress management and immediate nontrauma-

specific interventions

It is widely believed that exposure to a traumatic event

should be followed by acute distress management to

relieve emotional distress, reduce pain and provide basic

physiological needs and healthcare after the traumatic

event [5,12,50]. Immediate psychoeducative information

and advice, as well as other nontrauma-specific interven-

tions, such as psychological support, nonspecific stress

management, family interventions and family-centered

decision making, have been often discussed as potential

preventive measures for the development of posttrau-

matic stress [51,52]. However, so far there are no RCTs or

open studies that have provided any evidence for the

efficacy of psychoeducative interventions or other non-

trauma-specific interventions [53].

Psychological debriefing

Psychological debriefing, a single-session individual

or group intervention offering educational information

about common trauma reactions and encouraging the

expression of thoughts and feelings about the traumatic

experience, is widely used by many first responders and

governmental departments and agencies in the first hours

following a ‘critical incident’. However, RCTs and sys-

tematic reviews examining psychological debriefing

during the last decade have shown limited evidence

of efficacy in reducing psychological distress after

traumatic incidents in the short term or reducing the

probability of developing PTSD in the long run [3,6,7,9].

Importantly, there have been some indications that

debriefing might have been even disadvantageous

in the long term [7,54–56]. Several authors have

suggested that psychological debriefing involves prema-

ture re-exposure to traumatic memories, prolonging

peritraumatic distress, and thereby increasing fear con-

ditioning andmemory consolidation, which can interfere

with the natural course of recovery.

These negative results for psychological debriefing have

led to a paucity of new RCTs and open studies during the

last years. Recently, Hawker et al. [57] suggested several

limitations of these studies (study protocol and target

group violations, sample bias, and so on) that might at

least in part be responsible for the apparent failure of

psychological debriefing to prevent posttraumatic stress.

Furthermore, these authors pointed out that psycho-

logical debriefing was not originally designed for patients

after trauma exposure, but instead for professionals

routinely exposed to critical incidents in the course of

their work, who are briefed together in a group before and

after exposure.

Immediate trauma-focused cognitive behavioral

interventions

To date, there are no RCTs to determine the efficacy of

brief cognitive behavioral interventions in the immediate

aftermath of a traumatic experience to reduce posttrau-

matic stress symptoms.

Early interventionsThis chapter focuses on interventions applied within the

first days, weeks or months after trauma exposure.

Cognitive behavioral interventions

In contrast to immediate interventions, there is some

evidence for the efficacy of cognitive behavioral therapy

(CBT) approaches early, that is, within days or weeks

after exposure to a traumatic event [58,59].

Studies on peritraumatic and acute-phase stress response

have identified distorted cognitive appraisals as a major

harbinger of later PTSD [60–63]. It is suggested that

PTSD symptoms become persistent when the individual

processes the trauma in a way that leads to a continuing

sense of serious, current threat [61]. CBT approaches use

cognitive strategies targeting negative cognitive appraisal

(over-generalized views of the world as dangerous,

uncontrollable and unpredictable) and persistent avoid-

ance of reminders interfering with fear extinction learn-

ing [61,64]. CBT approaches also encourage the

(re-)establishment and maintenance of close relation-

ships with family and friends, in spite of the symptoms

that the individual is currently experiencing [65]. Finally,

CBT also addresses low self-efficacy, both as a pre-

existing personality trait and as a response to helplessness

experienced during exposure [66].

Brief trauma-focused cognitive behavioral therapy

interventions

Although the exact protocol may vary among studies,

brief trauma-focused CBT (TF-CBT) is a four to

12-session brief intervention beginning within the first

weeks after a traumatic event, including psychoeducation,

relaxation and stress management, affective expression

and modulation, cognitive coping, prolonged imaginal

Behavioral interventions after trauma Agorastos et al. 529

exposure, in-vivo exposure and cognitive reprocessing. In

the prevention of posttraumatic symptoms, TF-CBT

applied within the first weeks after traumatic exposure

is effective, as demonstrated by RCTs and meta-analytic

reviews [4,9,67–69]. In addition,TF-CBTadministered in

the weeks following exposure has been shown to prevent

chronic PTSD in patientswith initial acute stress reactions

and was more effective than no treatment, or other treat-

ments including self-help groups, in several studies

[2,11�,70,71]. To date, TF-CBT is the best-supported

empirical treatment for preventing chronic posttraumatic

stress symptoms.

Multisession psychological interventions

Multisession psychological interventions (MPI) are

normally implemented within the first weeks to months

following a traumatic event. However, treatment pro-

tocols are far less standardized, as MPI are not a specific

entity of interventions. This affects the comparability

of different studies, making it difficult to assess their

efficacy. Although many studies have reported positive

effects of CBT-oriented MPI [8,72], a meta-analysis

by Roberts et al. [1] failed to find efficacy of MPI inter-

ventions and concluded that these interventions should

not be used in routine treatment following traumatic

events.

Other early interventions

There are only very sparse data on various other psycho-

logical interventions targeting the prevention of acute

and posttraumatic stress symptoms.

Collaborative care interventions include many different

treatment principles and management strategies through

the integration of mental health professionals in primary

care settings and their close collaboration with other

medical and nursing staff, as well as social workers and

other healthcare providers. In order to simultaneously

assess patients in acute care, collaborative care uses

multifaceted interventions including standardized medi-

cal care, psychotherapeutic and psychopharmacological

interventions, long-term follow-up, and family interven-

tions. In the last few years, collaborative care interven-

tions have also gained interest in the prevention of

PTSD, but are still sparsely investigated in the literature

[73,74]. In addition, the multitude of different psycho-

social, psychotherapeutic and pharmacological inter-

ventions, as well as the often nonstandardized or

noncomparable study protocols across different studies,

are important limiting factors in determining efficacy for

the prevention of PTSD.

Virtual reality-based interventions may also gain import-

ance in the future. These interventions are designed to

allow activation and processing of traumatic memories

as a specific traumatic exposure treatment and might

be more useful and appealing to some individuals

(i.e. traumatized soldiers) compared with traditional

psychotherapeutic treatment options. However, RCTs

are still needed to assess the efficacy of virtual reality

exposure therapy in the prevention of acute and post-

traumatic stress symptoms [75–77].

DiscussionTraumatic events often lead to significant physical and

psychological symptoms as well as functional impairment

in trauma victims. Thus, the need for effective preven-

tion strategies is apparent. However, there is a lack of

evidence for several psychological and behavioral pre-

ventive interventions that have been implemented for

years despite their doubtful efficacy.

Concerning the interventions in the immediate aftermath

of a traumatic exposure, most studies to date have

focused on psychological debriefing, finding little evi-

dence for its efficacy in civilian trauma populations. Some

studies even raised concerns about an increased risk for

chronic PTSD after psychological debriefing.

Importantly, there is so far no study that has examined

brief cognitive behavioral interventions in the first hours

or even in the first 48–72 h following exposure to a

traumatic event. This could be a promising approach,

because early trauma-focused CBT interventions in

the first weeks after trauma exposure show the strongest

evidence and appear to be most efficient in the preven-

tion of acute and posttraumatic symptoms [59,78].

For other early interventions there is no, or only a low

level of, evidence. However, it is currently difficult to

compare studies because of nonstandardized, varying

study protocols and assessment methods [58]. The differ-

ent nature of interventions, the varying time points of

initial assessments, the amount of exposure and the total

hours of intervention, as well as the large numbers of

traumatized individuals with low risk of developing post-

traumatic symptoms complicate the interpretation of

these findings. For example, Roberts et al. [4] showed

in their meta-analysis that there was no significant differ-

ence between any type of psychological intervention and

treatment if all patients with trauma exposure were

included, whether or not they were symptomatic. How-

ever, when specific traumatic stress symptoms were

already apparent, TF-CBT was more effective than

control conditions.

Therefore, many authors suggest that exposure to a

traumatic event should be followed by immediate

detailed global assessment, including documentation of

trauma type, careful rating of early posttraumatic symp-

toms and identification of individual risk factors for the

530 Clinical therapeutics

development of a PTSD [5,8,79]. This kind of assess-

ment may play a role in determining high-risk individuals

who should receive psychological services immediately

after experiencing a traumatic event [80]. Therefore,

further development of effective screening tools is of

utmost importance [81].

In summary, among several psychological interventions

aiming to prevent acute and posttraumatic stress symp-

toms, only brief CBT-specific interventions including

imaginal and in-vivo exposure administered several

weeks after exposure to those with posttraumatic stress

symptoms show empirical evidence in the literature. No

psychological interventions administered in the first

hours, or even the first 72 h, have proven efficacy for

preventing posttraumatic stress symptoms. Importantly,

so far, no study has assessed the efficacy of immediate

cognitive behavioral interventions after a traumatic event

despite their efficacy if applied weeks after the trauma.

Furthermore, given the different and simultaneously

used components of various interventions, a closer exami-

nation of the efficacy of the different treatment com-

ponents (exposure components, cognitive restructuring,

and so on) in the future would be of great importance

[71,82].

ConclusionAlthough the prevention of acute and posttraumatic

stress after a traumatic event is an issue of major import-

ance, empirical data on the efficacy of immediate and

early psychological interventions following trauma

exposure is generally still limited. Further RCTs are

urgently needed to determine the best time point for

behavioral interventions after trauma exposure, the

efficacy of different types of behavioral interventions,

and which individuals might benefit the most from these

interventions.

AcknowledgementsAll authors have contributed to, read and approved the final version ofthe manuscript.

Conflicts of interestThere are no conflicts of interest.

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